Intrathecal Labor Analgesia Research Articles

The Relationship of Pharmacological Intrathecal Labor Analgesia in Normal Delivery with the Stability of Vital Sign of Newborn

Intrathecal Labor Analgesia (ILA) is a pharmacological therapy technique to reduce delivery pain. The research objective was to determine the relationship between ILA pharmacological therapy in normal delivery and the stability of the vital signs of newborns at X Hospital from January 2018 to May 2020. This study was conducted from September 2020 to January 2021 on 143 normal birth mothers with ILA pharmacological therapy and 943 mothers giving birth normal without pharmacological therapy. The results showed that there was no significant relationship between the APGAR score in the first minute of newborns with ILA pharmacological therapy in normal delivery p value = 0.369, the APGAR score in the fifth minute of newborns with ILA pharmacological therapy in normal delivery p value = 1,000 and the baby's heart rate. newborn with ILA pharmacological therapy in normal delivery p value = 0.616. There is a significant relationship between body temperature of newborns with pharmacological therapy in normal delivery p value = 0.001 and respiratory rate of newborns with pharmacological therapy in normal delivery p value = 0.045. Efforts made include advising mothers to breastfeed on demand, aiming to prevent hypoglycemia, which is a complication that often occurs in hypothermic babies and can cause respiratory problems. Health workers in delivery rooms to be more aware of newborn monitoring.

The relationship of bupivacaine and ropivacaine with the smoothness of breast milk in maternity patients

Introduction: Breast milk is the most crucial source of nutrition containing essential substances for a child’s immunity against diseases can digest solid food. The medical world always strives to find appropriate methods to reduce pain during labor, called Intrathecal Labor Analgesia (ILA) method. This study aims to analyze the relationship of bupivacaine and ropivacaine with the smoothness of breast milk in maternity patients. Methods: The patients were given analgesic drugs to determine the effect on their fluencies of breast milk within 24 hours. This research was conducted by doing medical record intervention toward the patients’ identity, drugs, and ILA doses and observing them through giving questionnaires for the treatment of post-partum through the ILA method at a puerperal room of the hospital.

Dexmedetomidine versus fentanyl as adjunct to ropivacaine-dexamethasone for labor analgesia: a randomized control study

Background and aims Although intrathecal analgesia is an effective option during labor, there is a need to establish sustainable and assured analgesia during the entire labor process. We aimed to compare the effect of dexmedetomidine versus fentanyl as an adjuvant to low-dose ropivacaine-dexamethasone for intrathecal labor analgesia in primigravida women.Patients and methods The study was conducted after approval of ethical committee of Al Azhar University Hospital. A total of 60 primiparous women classified in American Society of Anesthesiologists classes II with a singleton pregnancy in active labor were given combined spinal epidural analgesia. This was a double-blind randomized controlled trial that allocated them in two groups of 30 patients each. Group I received intrathecal 2.5 mg of 0.1% ropivacaine (diluted to 2.5 ml with normal saline)+5 μg dexmedetomidine+4 mg dexamethasone. Occurrence of any adverse reaction was observed for ten min. Group II received 25 μg of fentanyl instead of 5 μg dexmedetomidine. For both groups, epidural top-ups of 10 ml of 1% ropivacaine were given when parturients complained of two painful contractions (visual analog scale ≥4), after epidural test dose of 3 ml of 0.5% ropivacaine was slowly injected via epidural catheter and no occurrence of adverse reaction was observed 10 min later. Data collected were demographic profile of the patients, intrathecal block characteristics, needs for epidural activation before delivery, and maternal and fetal adverse effects. The primary study goal was to prove the analgesic efficacy and safety of intrathecal selective sensory block on both mother and fetus, whereas the study secondary goal was to prove that intrathecal single dose injection could be used as an effective alternative option in labor analgesia as well as epidural analgesia. Catecholamine level (epinephrine and norepinephrine) was measured using enzyme-linked immunosorbent assay technique.Results The mean age (years), weight (kg), height (cm), and BMI (kg/m2) in group I were 24.3±3.30, 65.4±16.2, 161.3±4.6, and 22.3±3.4, respectively, whereas in group II were 25.23±4.44, 66.3±15.6, 160.4±4.3, and 22.2±3.1, respectively, with insignificant difference (P>0.05). Mean visual analog scale score before onset of analgesia in group I and group II was 8.59±1.22 and 8.7±1.14, respectively. The time to full cervical dilatation was 120.14±10.2 in group I and 120.0±10.6 in group II, and the mean duration of second stage of labor was 12.02±1.37 min in group I and 11.83±0.93 min in group II. The mean duration of analgesia was statistically significant (lower) in group II (221.83±22.26) as compared with group I (296.33±44.83) (P<0.001). The mean analgesia in group I (12.3±1.8) and group II (12.1±1.7) was statistically insignificant (P>0.05). The mean highest sensory levels in group I and group II were statistically insignificant, that is, T5 (T4–T8) versus T6 (T4–T7) (P>0.05). The sensory region time in group II was greater (241.83±22.26 min) as compared with group I (329.83±44.10), with P value less than 0.001. Neither maternal nor fetal adverse events were statistically significant different between both groups (P>0.05). The mean basal norepinephrine level in pg/ml in group I was 130.30±27.6 and in group II was 103.50±20.6, with P value more than 0.05. At 2 h, norepinephrine level in pg/ml was 119.90±24.1 in group I and 90.50±13.6 in group II, with P value more than 0.05. At baseline, the epinephrine level in pg/ml in group I and group II was 59.20±11.3 and 53.20±10.3, respectively, whereas at 2 h, the epinephrine level in pg/ml was 57.90±9.1 in group I and 49.20±8.6 in group II, with P value more than 0.05.Conclusion Ropivacaine-dexamethasone combined with dexmedetomidine for intrathecal block achieved a potent selective sensory block with prolonged duration of analgesia, delayed S1 regression time, and limited maternal and fetal adverse effects than intrathecal ropivacaine-dexamethasone combined with fentanyl. However, dexmedetomidine or fentanyl provides a safe and efficacious adjuvant to intrathecal ropivacaine-dexamethasone in primigravida women with rapid onset, profound analgesia, and hemodynamic stability throughout the labor.

Comparison of Quality of Labor Analgesia by NPRS Score Upon Single Dose Intrathecal Labor Analgesia Between Bupivacaine With Adjuvants

Comparison of Quality of Labor Analgesia by NPRS Score Upon Single Dose Intrathecal Labor Analgesia Between Bupivacaine With Adjuvants

Study of effect of intrathecal labor analgesia using fentanyl 25μg alone and fentanyl 20μg plus bupivacaine 2.5mg on the progress of labor at a teaching hospital

Study of effect of intrathecal labor analgesia using fentanyl 25μg alone and fentanyl 20μg plus bupivacaine 2.5mg on the progress of labor at a teaching hospital

Outcomes of intrathecal analgesia in multiparous women undergoing normal vaginal delivery: A randomised controlled trial.

Background and Aims:Although intrathecal analgesia is an effective option during labour, there is a need to establish sustainable and assured analgesia during the entire labour process. We aimed to assess the effect of adding dexmedetomidine, fentanyl or morphine to low-dose bupivacaine-dexamethasone for intrathecal labour analgesia in multiparous women.Methods:This was a triple-blind, randomised controlled trial that included 140 multiparous women. Eligible women were randomly allocated to have intrathecal bupivacaine-dexamethasone with dexmedetomidine (group D), fentanyl (group F), morphine (group M) or saline (placebo) (group C). The duration of analgesia, intrathecal block characteristics and maternal and foetal outcomes were assessed and analysed.Results:The longest analgesia duration and S1 regression time was recorded in group D followed by groups M, F and C, respectively, with statistical significance between all of them (P < 0.001). The shortest analgesia onset time and the highest sensory levels were recorded in group D followed by group F then group M with statistical significance between all of them (P < 0.001 and 0.003, respectively). Visual analogue scale values were comparable among groups M, F and D (P > 0.05) at most of the measurement time points and at the peak of the last uterine contraction before delivery while being significantly lower than those in group C (P < 0.001). However, there were similar motor block characteristics and normal neonatal outcomes in all groups.Conclusion:In comparison to morphine and fentanyl, dexmedetomidine addition to intrathecal bupivacaine-dexamethasone significantly prolonged the duration and accelerated the onset of labour analgesia, with a good maternal and neonatal outcome.

Effect of intrathecal labor analgesia using fentanyl 25 μg and bupivacaine 2.5 mg on progress of labor

Background: The aim of this study was to evaluate the progress of labor and hemodynamic changes in the mother and fetus with intrathecal analgesia using bupivacaine and fentanyl during normal vaginal delivery. Materials and Methods: Sixty nulliparous parturients in the active phase of labor with a cervical dilatation of >3 cm were selected for this prospective study. Group SA (n = 30) received an intrathecal injection of 0.5% hyperbaric bupivacaine 2.5 mg and fentanyl 25 μg and compared with Group C (n = 30) who refused to give consent for neuraxial analgesia. Visual analog score, progress of labor, maternal hemodynamic variations, and fetal heart rate were recorded. Statistical analysis included an unpaired and paired two-tailed t-tests. Result: Duration of the active phase of first stage of labor was shortened in group SA as compared to group C (115.50 vs. 134.0 min, P < 0.05). Duration of second stage of labor was prolonged in group SA as compared to group C (18.03 vs. 10.13 min, P < 0.05). Rate of cervical dilation was faster in group SA as compared to group C (3.021 vs. 2.486 cm/h, P < 0.05). Mean visual analog score, pulse rate, and mean arterial pressure was significantly decreased as compared to the baseline in group SA. No significant changes were noted in the fetal heart rate as compared to the baseline in both groups. Conclusions: Single-shot intrathecal analgesia using fentanyl 25 μg and bupivacaine 2.5 mg in active phase of first stage of labor associated with fast cervical dilation rate and no delay in the progress of labor.

The Effect of Intravenous Magnesium Therapy on the Duration of Intrathecal Fentanyl Labor Analgesia

The Effect of Intravenous Magnesium Therapy on the Duration of Intrathecal Fentanyl Labor Analgesia

The comparison of clinically relevant doses of intrathecal ropivacaine and levobupivacaine with fentanyl for labor analgesia

BackgroundIntrathecal labor analgesia using new local anesthetics such as ropivacaine or levobupivacaine becomes more popular by virtues of their safety and decreased motor weakness. However, the analgesic efficacy of the clinically effective intrathecal doses of these new local anesthetics combined with fentanyl has yet to be determined.MethodsSixty parturients who requested neuraxial analgesia in early active labor were randomly assigned to either ropivacaine (group R, n = 30) or levobupivacaine (group L, n = 30) group. Group R received 3 mg of intrathecal ropivacaine and the group L received 3 mg of intrathecal levobupivacaine mixed with 20 µg of fentanyl as part of a combined spinal-epidural (CSE) technique. The associated block parameters, such as pain scores, duration of analgesia, the highest levels of the sensory block and motor block scores 30 mins after the injection were compared between two groups.ResultsIntrathecal ropivacaine offered shorter analgesia (87 ± 41 min vs. 122 ± 56 min, P < 0.05) with lower sensory height (T8.5 vs. T6, P < 0.05) and led to lower incidence of complete analgesia (73 vs. 97%, P < 0.05) compared with intrathecal levobupivacaine. Although motor weakness was comparable in both groups, significantly weak perineal squeezing was noticed in Group L (7 of 30 parturients vs. 16 of 30, P < 0.05).ConclusionsClinically relevant doses of intrathecal levobupivacaine in combination with fentanyl as part of a CSE technique provides more effective analgesia than equivalent doses of intrathecal ropivacaine in early labor, but is accompanied by slight motor weakness.

Effects of Epidural Clonidine and Neostigmine Following Intrathecal Labor Analgesia: A Randomized, Double-blind, Placebo-controlled Trial

Van de Velde, M.; Berends, N.; Kumar, A.; Devroe, S.; Devlieger, R.; Vandermeersch, E.; De Buck, F. Author Information

Effects of epidural clonidine and neostigmine following intrathecal labour analgesia: a randomised, double-blind, placebo-controlled trial

Background The limited duration of spinal labour analgesia combined with problems associated with maintenance of epidural analgesia, have prompted the search for combinations that could prolong spinal analgesia. A randomised, double-blind trial was carried out to test the hypotheses (a) that initial spinal labour analgesia is prolonged by administering clonidine and neostigmine epidurally whilst (b) the hourly local anaesthetic consumption is reduced. Methods Seventy labouring patients received spinal analgesia with ropivacaine and sufentanil. Fifteen minutes after spinal injection, 10 mL of study solution was administered epidurally. The study solution was plain saline or neostigmine 500 μg combined with clonidine 75 μg. Outcome parameters were duration of spinal analgesia, local anaesthetic consumption and number of patients delivering without additional epidural analgesia. Results Epidural clonidine and neostigmine significantly prolonged initial analgesia: 144 (105–163) min vs. 95 (70–120) min in the placebo group and reduced hourly ropivacaine consumption: 7.5 (3.0–11.9) mg vs. 12.7 (9.6–16.9) mg. More patients in the experimental group delivered before the first request for additional analgesia (9 vs. 2). Conclusion Epidural administration of neostigmine 500 μg and clonidine 75 μg, following the intrathecal injection of ropivacaine and sufentanil, prolongs analgesia and reduces hourly ropivacaine consumption.

A Randomized, Double-Masked, Multicenter Comparison of the Safety of Continuous Intrathecal Labor Analgesia Using a 28-Gauge Catheter Versus Continuous Epidural Labor Analgesia

Arkoosh, V.A.; Palmer, C.M.; Yun, E.M.; Sharma, S.K.; Bates, J.N.; Wissler, R.N.; Buxbaum, J.L.; Nogami, W.M.; Gracely, E.J. Author Information

A Randomized, Double-masked, Multicenter Comparison of the Safety of Continuous Intrathecal Labor Analgesia Using a 28-Gauge Catheter versus Continuous Epidural Labor Analgesia

Continuous intrathecal labor analgesia produces rapid analgesia or anesthesia and allows substantial flexibility in medication choice. The US Food and Drug Administration, in 1992, removed intrathecal microcatheters (27-32 gauge) from clinical use after reports of neurologic injury in nonobstetric patients. This study examined the safety and efficacy of a 28-gauge intrathecal catheter for labor analgesia in a prospective, randomized, multicenter trial. Laboring patients were randomly assigned to continuous intrathecal analgesia with a 28-gauge catheter (n = 329) or continuous epidural analgesia with a 20-gauge catheter (n = 100), using bupivacaine and sufentanil. The primary outcome was the incidence of neurologic complications, as determined by masked neurologic examinations at 24 and 48 h postpartum, plus telephone follow-up at 7-10 and 30 days after delivery. The secondary outcomes included adequacy of labor analgesia, maternal satisfaction, and neonatal status. No patient had a permanent neurologic change. The continuous intrathecal analgesia patients had better early analgesia, less motor blockade, more pruritus, and higher maternal satisfaction with pain relief at 24 h postpartum. The intrathecal catheter was significantly more difficult to remove. There were no significant differences between the two groups in neonatal status, post-dural puncture headache, hemodynamic stability, or obstetric outcomes. Providing intrathecal labor analgesia with sufentanil and bupivacaine via a 28-gauge catheter has an incidence of neurologic complication less than 1%, and produces better initial pain relief and higher maternal satisfaction, but is associated with more technical difficulties and catheter failures compared with epidural analgesia.

Instructions for Obtaining Journal CME Credit

Anesthesiology’s journal-based CME program is open to all readers. Members of the American Society of Anesthesiologists participate at a preferred rate, but you need not be an ASA member or a journal subscriber to take part in this CME activity. Please complete the following steps:The American Society of Anesthesiologists is approved by the Accreditation Council for Continuing Medical Education (ACCME) to sponsor continuing medical education programs for physicians.The American Society of Anesthesiologists designates this educational activity for a maximum of 1 AMA PRA Category 1 Credit™ . Physicians should only claim credit commensurate with the extent of their participation in the activity.Purpose: The focus of the journal-based CME program, and the articles chosen for the program, is to educate readers on current developments in the science and clinical practice of the specialty of Anesthesiology.Target Audience: Physicians and other medical professionals whose medical specialty is the practice of anesthesia.Learning Objectives: After reading this article, participants should understand the risks and benefits of intrathecal microcatheters versus continuous epidural catheters for labor analgesia.Authors – Valerie A. Arkoosh, M.D., M.P.H., Craig M. Palmer, M.D., Esther M. Yun, M.D., Shiv K. Sharma, M.D., F.R.C.A., James N. Bates, Ph.D., M.D., Richard N. Wissler, M.D., Ph.D., Jodie L. Buxbaum, M.D., Wallace M. Nogami, M.D., and Edward J. Gracely, Ph.D.Grants or research support: Supported by Ballard Medical Inc., Salt Lake City, Utah (successor to Preferred Medical Products, Inc.), a division of Kimberly-Clark.Consultantships or honoraria: NoneAuthors – Kenneth Drasner, M.D., and Richard Smiley, M.D., Ph.D.Grants or research support: NoneConsultantships or honoraria: The article authored by Drs. Drasner and Smiley was supported solely from institutional and/or departmental sources.Question Writer – Leslie C. Jameson, M.D.Dr. Jameson has no grants, research support, or consultant positions, nor does she receive any honoraria from outside sources, which may create conflicts of interest concerning this CME program.Based on the article by Arkoosh et al . entitled “A randomized, double-masked, multicenter comparison of the safety of continuous intrathecal labor analgesia using a 28-gauge catheter versus continuous epidural labor analgesia” and its accompanying editorial by Drasner and Smiley entitled “Continuous spinal analgesia for labor and delivery: A born-again technique?” in the February issue of Anesthesiology, choose the one correct answer for each question:1. Which of the following statements about case reports in 1992 of neurologic injury associated with the use of intrathecal microcatheters (27–32 gauge) introduced through a 22–26 gauge needle is most likely true?A. All affected patients experienced an intrathecal hematoma.B. Complications occurred exclusively in obstetric patients.C. The Food and Drug Administration withdrew approval of all catheters in the intrathecal space.D. A neurologic complication occurred primarily with the use of a hyperbaric solution of 5% lidocaine.2. The authors of the current study compared neurologic complications, analgesic effectiveness, and neonatal outcome between standard continuous epidural (CEPI) analgesia and continuous intrathecal (CIT) analgesia administered through a 28-gauge microcatheter. Which of the following statements about their research protocol is most likely true?A. CIT patients received a continuous infusion of sufentanil and a bupivacaine bolus for breakthrough pain.B. Patients with preeclampsia were allowed to enroll in the study.C. To detect a permanent neurologic deficit rate for CIT patients equivalent to that reported with CEPI patients would require study enrollment of 100 patients.D. Patient assessment only occurred 24 h after delivery.3. When comparing the neurologic outcomes of the continuous intrathecal (CIT) and continuous epidural (CEPI) techniques, which of the following statements is most likely true?A. Postpartum weakness or loss of sensation occurred at the same frequency in both groups.B. CIT patients were significantly more likely to require a blood patch to treat a postpartum headache.C. CIT patients had less effective pain relief.D. Motor blockade caused fewer CEPI patients to have successful vaginal deliveries.4. When comparing outcomes of the continuous intrathecal (CIT) and continuous epidural (CEPI) techniques, which of the following statements is most likely true?A. CIT patients were more likely to require treatment for systemic hypotension.B. CEPI patients reported a higher pruritus score.C. Fetal bradycardia was more frequent in the CEPI-treated mothers.D. Twenty-four hours after delivery, patient satisfaction was significantly greater in the CIT group.5. Which of the following statements about the catheters used in the continuous intrathecal (CIT) and continuous epidural (CEPI) techniques is most likely true?A. Tensile strength of a 28-gauge microcatheter is the same as a standard 22-gauge epidural catheter.B. CIT catheters are significantly more difficult to remove than CEPI catheters.C. The CIT catheters were placed with a midline approach to improve ease of removal.D. One CEPI catheter broke inside the patient’s body.

Determination of the Full Dose–Response Relation of Intrathecal Bupivacaine, Levobupivacaine, and Ropivacaine, Combined with Sufentanil, for Labor Analgesia

Ropivacaine and levobupivacaine are local anesthetics that produce less motor block and greater sensory-motor separation when compared with equal milligram doses of bupivacaine. Although minimum local analgesic concentration studies suggested that they are less potent than bupivacaine, full dose-response studies have not been performed. The current trial describes the dose-response relation of levobupivacaine, ropivacaine, and bupivacaine, combined with sufentanil, when used for intrathecal labor analgesia. Four hundred fifty term parturients in active labor were included in this double-blind, randomized trial. Combined spinal-epidural anesthesia was performed, and ropivacaine, levobupivacaine, or bupivacaine was intrathecally administered in a dose of 1.0, 1.5, 2.0, 2.5, 3.0, or 3.5 mg, always combined with 1.5 microg sufentanil. Patients were considered responders to spinal analgesia if the visual analog scale score for pain was less than 25 mm within 15 min and the visual analog scale score remained less than 25 mm for 45 min. Patient demographics, obstetric data, maternal side effects, and fetal and neonatal well-being were noted. Group-specific dose-response curves were constructed using a probit regression model. The ED95 of bupivacaine was 3.3 mg (95% confidence interval, 2.9-4.1). The ED95s of ropivacaine and levobupivacaine were 4.8 mg (95% confidence interval, 4.0-6.7) and 5.0 mg (95% confidence interval, 4.1-7.0), respectively. Racemic bupivacaine was significantly more potent than ropivacaine (P=0.0027) and levobupivacaine (P=0.0006). Ropivacaine and levobupivacaine were of similar potency (P=0.91). This full dose-response study suggests that ropivacaine and levobupivacaine are of similar potency, whereas bupivacaine is more potent than both other drugs.

Body habitus does not influence spread of sensory blockade after the intrathecal injection of a hypobaric solution in term parturients

To determine if the extent of sensory blockade after the intrathecal injection of hypobaric fentanyl (25 micro g) and bupicavaine (2.5 mg) in the sitting position in term parturients is influenced by body habitus. A prospective observational study in 245 term parturients who received intrathecal fentanyl and bupivacaine plus an epidural test dose to initiate labour analgesia at an academic university hospital. The highest sensory blockade to ice and pinprick was determined at 15 and 30 min after the intrathecal injection. Correlations between sensory blockade and parturient height, weight and body mass index (BMI) were determined. There was no association between highest sensory blockade and parturients' height. Increasing weight and BMI were associated with increased cephalad sensory blockade at 15 min, but not at 30 min. The estimated difference in sensory level between women at the extremes of BMI, based on our linear regression model, was less than one dermatome. Height did not influence the extent of sensory analgesia after initiation of intrathecal labour analgesia using a hypobaric solution injected with the parturient in the sitting position. Weight and BMI were associated with a non-clinically significant increase in the cephalic spread of analgesia, suggesting that dose adjustments based on body habitus in this population are not necessary.

Influence of Height, Weight and Patient Position on Sensory Level after Intrathecal Labor Analgesia with a Hypobaric Solution

Influence of Height, Weight and Patient Position on Sensory Level after Intrathecal Labor Analgesia with a Hypobaric Solution

Intrathecal labor analgesia with bupivacaine and sufentanil: The effect of adding 2.25 μg epinephrine

Background and Objectives: Epinephrine, 25 μg and 200 μg, has been found to prolong the duration of intrathecal labor analgesia when added to an opioid. In our hospital we use the standard epidural mixture, prepared by the pharmacist, containing epinephrine 1:800,000; i.e., 1.25 μg/mL for both spinal and epidural labor analgesia. We wanted to evaluate whether such a low dose, depending on its effect on duration or quality of analgesia, should be maintained or deleted in future mixtures. Methods: Forty-five term parturients were randomly assigned to receive 1.8 mL intrathecally of a mixture containing bupivacaine 0.125% and sufentanil 0.75 μg/mL with or without epinephrine 1.25 μg/mL. The quality and duration of analgesia, side effects, and obstetric/neonatal outcome were compared. Results: For both combinations, the onset until the first painless contraction was between 5 and 6 minutes. Most patients were pain free during the second uterine contraction. The duration of complete analgesia was 93.2 ± 24.2 minutes in the epinephrine group and 79.3 ± 18.1 minutes for patients not receiving epinephrine ( P = .014). The quality of the block, bupivacaine consumption, side effects, and obstetric/neonatal outcome were not different between groups. Conclusions: It was concluded that epinephrine in a dose as low as 2.25 μg significantly prolonged the duration of intrathecal analgesia of bupivacaine-sufentanil by 15 minutes. No other differences were noticed. Diluting the commercially available bupivacaine 0.5% with epinephrine 1:200,000 may avoid the need of freshly prepared epinephrine solutions. Reg Anesth Pain Med 2001;26:473-477.

SOAP 30th Annual Meeting

SOAP 30th Annual Meeting

Continuous Intrathecal Labor Analgesia

Continuous Intrathecal Labor Analgesia